Self-report Assessment of Metacognition Among Schizophrenia Patients: A Systematic Review

Abstract

Purpose of the Review:

Metacognition is the ability to reflect on and regulate one’s own cognitive processes. It is increasingly recognized as a critical factor in schizophrenia, influencing insight, treatment adherence, and functional outcomes. Self-report tools are widely used to assess metacognition, but their reliability, validity, and clinical applicability remain debated.

Collection and Analysis of Data:

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with International Prospective Register of Systematic Reviews (PROSPERO). A total of five electronic databases (PubMed, PsycINFO, Embase, Web of Science, and Scopus) were searched for studies published between 2014 and 2024. Eligibility was defined by the Population, Intervention, Comparison, Design (PICO-D) framework, focusing on adults with schizophrenia or schizoaffective disorder assessed with self-report metacognition measures. Study quality was appraised using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. Of 2,437 records screened, 36 studies were included. Data were narratively synthesized, with statistical properties such as internal consistency (Cronbach’s α), test–retest reliability, and factor structures summarized. Most tools, including the Beck Cognitive Insight Scale (BCIS), Metacognition Assessment Scale (MAS), and Metacognitions Questionnaire (MCQ-30), demonstrated high internal consistency (α = 0.70–0.95) and satisfactory construct validity. Findings consistently linked metacognitive deficits to greater symptom severity, poor social functioning, and reduced treatment response, while higher self-reflection and cognitive flexibility predicted improved clinical and vocational outcomes. However, limitations included reliance on self-report accuracy, limited longitudinal validation, and inadequate cross-cultural adaptation.

Conclusions:

Self-report measures of metacognition in schizophrenia exhibit strong psychometric support and clear clinical utility for diagnosis, symptom monitoring, and rehabilitation planning.

Schizophrenia, affecting about 1% of the global population, is a complex disorder marked by disturbances in thought, perception, emotion, and behavior, posing major challenges for patients and clinicians.^1,2 Traditionally, research emphasized positive and negative symptoms, but there is increasing recognition that cognitive and metacognitive deficits are crucial for understanding and treating schizophrenia. Metacognition, broadly defined as “thinking about thinking,” encompasses the ability to reflect upon, understand, and regulate one’s own cognitive processes. ³ In recent years, interest in metacognition within schizophrenia has increased because metacognitive impairments have been shown to influence symptom expression, social functioning, and treatment responsiveness, highlighting its relevance for clinical care.^4–7 Metacognitive deficits in schizophrenia can manifest in various ways, including difficulties in self-reflection and theory of mind (ToM). ToM is the ability to infer and understand the thoughts, intentions, and emotions of others. This is a key component of social cognition and is often impaired in individuals with schizophrenia. ⁸ These impairments may contribute to poor insight, reduced treatment adherence, and difficulties in social functioning. ⁹

Self-report measures are valuable for assessing metacognition in schizophrenia, offering ease of use, cost-effectiveness, and the ability to capture subjective experiences that are not accessible to other methods. ¹⁰ However, the use of self-report measures in schizophrenia populations also presents unique challenges, such as potential biases due to impaired insight or cognitive deficits. ¹¹ Over the past three decades, self-report measures for metacognition in schizophrenia have advanced significantly. Early work by O’Neil et al. (1996) established the foundations for assessing awareness, strategy, planning, and self-checking. ¹² Subsequent research has expanded on this foundation, developing more specialized instruments tailored to the unique metacognitive profiles observed in schizophrenia.^13–17 Key measures that have emerged in this field include the Metacognition Assessment Scale (MAS), ¹⁸ the Beck Cognitive Insight Scale (BCIS), ¹⁹ and the Metacognitions Questionnaire (MCQ-30). ²⁰ These instruments have enhanced understanding of metacognitive functioning in schizophrenia and are widely used to explore its links with clinical and functional outcomes.

Despite the growth of self-report measures for metacognition in schizophrenia, a comprehensive critical review remains necessary. This systematic review, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, addresses this gap by identifying and evaluating current self-report instruments, analyzing their psychometric properties using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) framework, and examining their clinical utility and theoretical underpinnings. By synthesizing available evidence, this review highlights both strengths and limitations of existing measures, identifies gaps in assessment, and provides recommendations for tool selection in research and practice. To the best of our knowledge, this work presents the first psychometric map of self-report measures of metacognition in schizophrenia, aiming to inform improved assessment and intervention.

Methods

Search Strategy

This systematic review was conducted in accordance with the PRISMA guidelines (see the PRISMA checklist in the supplementary file) and was pre-registered in the PROSPERO database. The database searches were conducted between 12 and 28 November 2024. A comprehensive search was performed in PubMed, PsycINFO, Embase, Web of Science, and Scopus, covering studies published between 2014 and 2024. Studies published before 2014 were excluded because metacognition research and the development of self-report instruments for schizophrenia have undergone substantial conceptual and methodological refinement over the past decade. Many earlier tools lacked current psychometric standards, such as COSMIN-aligned validation, and did not reflect contemporary models of metacognition, cognitive insight, or functional outcomes. Limiting the review to 2014–2024 ensures that the included studies represent modern measurement practices and clinically relevant constructs. The search combined Medical Subject Headings (MeSH) and keywords related to metacognition, self-report measures, and schizophrenia. The main search terms included: (Metacognition OR “cognitive insight” OR “self-reflection” OR “self-awareness”) AND (schizophrenia OR psychosis OR “schizophrenia spectrum disorders”) AND (“self-report” OR questionnaire OR scale OR inventory). Search strategies were tailored for each database and are presented in Table 1.

Table 1.

Search Strategies Used for Databases.

Database	Search Terms
PubMed	(“Metacognition”[ MeSH] OR “Cognitive insight”[ MeSH] OR “Self-reflection”[Title/Abstract] OR “Self-awareness”[Title/Abstract]) AND (“Schizophrenia”[MeSH] OR “Psychosis”[MeSH] OR “Schizophrenia spectrum disorders”[Title/Abstract]) AND (“Self-report”[Title/Abstract] OR “Questionnaire”[Title/Abstract] OR “Scale”[Title/Abstract] OR “Inventory”[Title/Abstract])
PsycINFO	(DE “Metacognition” OR DE “Cognitive insight” OR TI/AB “Self-reflection” OR TI/AB “Self-awareness”) AND (DE “Schizophrenia” OR DE “Psychotic Disorders” OR TI/AB “Schizophrenia spectrum disorders”) AND (TI/AB “Self-report” OR TI/AB “Questionnaire” OR TI/AB “Scale” OR TI/AB “Inventory”)
Embase	(“metacognition”/exp OR “cognitive insight”/exp OR  “self-reflection”:ti,ab OR “self-awareness”:ti,ab) AND (“schizophrenia”/exp OR “psychosis”/exp OR “schizophrenia spectrum disorder”:ti,ab) AND (“self-report”:ti,ab OR “questionnaire”:ti,ab OR “scale”:ti,ab OR “inventory”:ti,ab)
Web of Science	TOPIC: (“Metacognition” OR “Cognitive insight” OR “Self-reflection” OR “Self-awareness”) AND TOPIC: (“Schizophrenia” OR “Psychosis” OR “Schizophrenia spectrum disorders”) AND TOPIC: (“Self-report” OR “Questionnaire” OR “Scale” OR “Inventory”)
Scopus	TITLE-ABS-KEY (“Metacognition” OR “Cognitive insight” OR “Self-reflection” OR “Self-awareness”) AND TITLE-ABS-KEY (“Schizophrenia” OR “Psychosis” OR “Schizophrenia spectrum disorders”) AND TITLE-ABS-KEY (“Self-report” OR “Questionnaire” OR “Scale” OR “Inventory”)

Study Selection

Title and abstract screening, as well as full-text assessment, were conducted independently by two reviewers. Any disagreements during screening were resolved through discussion and consensus; when consensus could not be reached, a third reviewer served as an arbitrator. All records were imported into Zotero for deduplication and then screened using Abstrackr to facilitate blinded independent review. Inter-rater agreement for the initial screening phase was calculated using Cohen’s κ, which indicated substantial agreement between reviewers. These procedures were implemented to minimize selection bias and enhance the transparency and reproducibility of the review process. Studies reporting multiple instruments contributed separate instrument-level data, but were counted once at the study level. When overlapping samples were identified across publications, the cohort was included only once, using the most complete dataset, with secondary articles contributing unique analyses. This prevented duplication of participant data and maintained accurate synthesis.

Eligibility Was Determined Using the PICO-D Framework

Population (P): Adults (≥18 years) with schizophrenia or schizoaffective disorder, diagnosed by Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

Intervention/exposure (I): Studies employing at least one self-report measure of metacognition, cognitive insight, self- reflection, or self-awareness.

Comparison (C): Studies comparing self-report measures to clinician-rated or performance-based assessments, healthy controls (HC), or other psychiatric groups were included if relevant.

Outcomes (O): Studies had to report psychometric properties (e.g., reliability, validity) or clinical utility of the self- report measures.

Study design (D): Included cross-sectional and longitudinal observational studies, validation studies, and randomized controlled trials; reviews, case reports, and conference abstracts were excluded.

The initial search identified 2,437 records. After removing 584 duplicates, 1,853 articles were screened by title and abstract. Studies that did not meet the inclusion criteria were excluded. Eighty-seven articles underwent full-text review; 36 met all criteria and were included in the final synthesis. The selection process is detailed in Figure 1 (PRISMA flow diagram).

Figure 1. PRISMA Flow Sequence Diagram.

Data Extraction and Synthesis

For each included study, data were extracted using a standardized form. Extracted information included study design, sample characteristics, details of the self-report measure(s) used, psychometric properties (reliability, validity, test–retest stability), and clinical utility (e.g., sensitivity to change, applicability in symptom assessment, or treatment monitoring). Given the heterogeneity of study designs and outcome measures, a narrative synthesis approach was employed. The synthesis emphasized the types and characteristics of self-report instruments, summary psychometric findings, and their practical application in schizophrenia research and clinical settings. Quantitative data, such as reliability coefficients or validity estimates, were summarized when possible.

Risk of Bias Assessment

The methodological quality of studies reporting psychometric properties was assessed using the COSMIN Risk of Bias tool, which evaluates domains including internal consistency, reliability, validity, responsiveness, and floor and ceiling effects. Each study was rated as very good, adequate, doubtful, or inadequate according to COSMIN criteria. Of the 38 initially eligible studies, two were excluded from the final synthesis due to a high-risk of bias related to insufficient reporting or inadequate sample sizes. The remaining 36 studies met quality standards and were included in the analysis.

Review and Interpretations

Categorization of Included Studies

Researchers have developed a range of tools to assess metacognitive abilities across diverse populations, from the general public to clinical groups with psychiatric disorders. This systematic review organizes the literature into four main areas: Metacognitive assessment tools, metacognitive functioning in psychopathology, social cognition and metacognition, and paranoia and metacognition. These four thematic categories were selected because they reflect the core domains necessary to address the review’s primary objectives: Identifying existing self-report measures, evaluating their psychometric properties, and understanding their clinical applicability in schizophrenia. “Metacognitive assessment tools and psychometric validation” directly aligns with the identification and appraisal of measurement instruments. “Metacognition and symptom severity,” “metacognition and functional outcomes,” and “metacognition and treatment response” were included because they capture the major clinical contexts in which self-report metacognition measures are applied and validated. Together, these categories provide a structured synthesis that links measurement properties with real-world clinical utility, consistent with the goals of this systematic review. Although paranoia may be viewed as a subcomponent of broader psychological outcomes, it was retained as a separate category because of its distinct theoretical and clinical significance in research on digital technology. Several prior studies assessed paranoia using dedicated measures and reported it as a discrete outcome; categorizing it separately ensured conceptual clarity and allowed for more accurate synthesis of findings (Freeman 2007). ²¹ The first area focuses on the development and validation of instruments to quantify metacognitive skills, laying the foundation for understanding cognitive self-regulation. The second area examines the impact of metacognitive abilities on mental health outcomes, especially among individuals with schizophrenia and related disorders. The third explores how metacognitive capacity shapes social cognition and interpersonal understanding. At the same time, the fourth investigates the connections between metacognition and paranoia, shedding light on how cognitive beliefs influence paranoid ideation. By structuring the review around these categories, a comprehensive perspective on the varied applications and significance of metacognitive research is achieved, emphasizing its value for both clinical and non-clinical populations. All 36 included studies were mapped to at least one of these four thematic categories based on their primary focus. Several studies, however, spanned multiple categories, for example, those that simultaneously reported psychometric validation and examined associations with symptom severity or functional outcomes. In such cases, studies were discussed in all relevant categories to ensure complete and accurate representation of their contributions.

The metacognitive assessment tools category comprises instruments designed to directly assess metacognitive processes, including self-reflectivity, mastery, monitoring, integration, and cognitive confidence. Representative tools include the MAS/MAS-A, the Metacognition Self-Assessment Scale (MSAS), the Metacognition Assessment Interview (MAI), the MCQ-30, and the Cognitive–Attentional Syndrome Questionnaire (CAS-1). These tools are detailed in Table 3 and evaluated for psychometric properties in Table 4.

Table 3.

Summary of Measures Used in Studies on Metacognition and Schizophrenia.

Measure	Purpose	Studies
BCIS	To assess the impact of MCT on cognitive insight and  positive symptoms in schizophrenia patients.	Simón-Expósito and Felipe-Castaño (2019), 19  Davies et al. (2017). 32
MCQ-30	To investigate the relationship between metacognitive beliefs, cognitive functioning, psychiatric symptoms,  and empathy in schizophrenia.	Chuang et al. (2021), 20 Morrison et al. (2015), 26  Popolo et al. (2017). 38
MAS	Assesses metacognition via narratives	Kilicoglu et al. (2024), 34 Popolo et al. (2017). 38
Self-reports	Critiques self-report reliability for metacognition	Craig et al. (2020). 31
MAI	To assess and measure an individual’s awareness  and regulation of their metacognition	Davies et al. (2017), 32 Wright et al. (2019A), 41  Wright et al. (2019B), 42 Wright et al. (2020). 43
Self-monitoring and self-regulation measures	Examines the cognition-metacognition link for  real-world functioning	Koren et al. (2006). 44
CBQp, MAQ, PSYRATS	Validates metacognition measures for schizophrenia	Erawati et al. (2014). 24
MSAS	Evaluates metacognitive abilities	Faustino et al. (2021), 33 Pedone et al. (2017). 36
Self-reflectivity, decentration	Examines metacognition’s impact on social functioning	Fischer et al. (2020). 29
BHS, RAS, RSES, QOLS	Investigates the role of metacognition in self-appraisal  and social functioning	James et al. (2016). 15
MCCB	Assesses cognitive deficits in schizophrenia	Hill et al. (2013), 8 Vita et al. (2022). 40
WCST	Measures executive function and cognitive flexibility	Lysaker et al. (2010), 23 Harris and Rempfer (2020). 30
Hinting task	Assesses ToM in schizophrenia	James et al. (2016). 15
CAS-1	Evaluates cognitive–attentional syndrome	Kowalski and Dragan (2019). 28
PANSS	Assesses schizophrenia symptom severity	Vohs et al. (2014), 9 Hochheiser et al. (2020), 1  Davies et al. (2017), 32 Wright et al. (2019), 41  Wright et al. (2019), 42 Wright et al. (2020). 43
BaPS	Links paranoia-related metacognitive beliefs to  schizophrenia	Morrison et al. (2015), 26 Murphy et al. (2017). 27
SLOF	Evaluates self-awareness of real-life functioning	Rocca et al. (2021). 17
Cognitive complaints and neuropsychological tests	Assesses cognitive complaints in schizophrenia	Raffard et al. (2020). 39
Serum levels of TNF-α, IL-6, and IL-18	Links inflammation to schizophrenia pathophysiology	Vohs et al. (2014). 9

* BCIS: Beck Cognitive Insight Scale, MCQ: Metacognitions Questionnaire, MAS: Metacognition Assessment Scale, MCT: Metacognitive Training, MAI: Metacognitive Awareness Interview, CBQp: Cognitive Bias Questionnaire for Psychosis, MAQ: Metacognitive Ability Questionnaire, PSYRATS: Psychotic Symptoms Rating Scale, MSAS: Metacognition Self-Assessment Scale, BHS: Beck Hopelessness Scale, RAS: Recovery Assessment Scale, RSES: Rosenberg self-esteem scale, QOLS: Quality of life scales, MCCB: MATRICS Consensus Cognitive Battery (Measurement and Treatment Research to Improve Cognition in Schizophrenia) Consensus Cognitive Battery, WCST: Wisconsin Card Sorting Test, CAS-1: Cognitive–Attentional Syndrome questionnaire, PANSS: Positive and Negative Syndrome Scale, BaPS: Beliefs About Paranoia Scale, SLOF: Specific Level of Functioning Scale, TNF-α: Tumor necrosis factor-alpha, IL-6: Interleukin-6, IL-8: Interleukin-8, ToM: Theory of mind.

Table 4.

Psychometric Properties of Self-report Metacognition Measures.

Author(s) and Year	Measure(s) Assessed	Reliability  (Cronbach’s Alpha)	Validity
Lysaker and Dimaggio (2014). 6	MAS	Not Reported	Validated in non-clinical and clinical populations
Bröcker et al. (2017). 18	MAS-A	0.65–0.86	Validated in the schizophrenia spectrum
Simón-Expósito and Felipe-Castaño (2019). 19	BCIS	0.56–0.8	Validated in a clinical population of schizophrenia patients
Erawati et al. (2014). 24	Indonesian CBQp,  PSYRATS, MAQ	0.759	Limited cross-validation
Gould et al. (2015). 25	CAI	Not Reported	Validated for real-world functioning
Murphy et al. (2017). 27	BaPS	0.87–0.89 for  subscales	Factor structure confirmed in paranoia studies
Kowalski and Dragan (2019). 28	CAS-1	0.85	Validated in non-clinical and clinical populations
Fischer et al. (2020). 29	Metacognitive capacity assessment	Not Reported	Validated against schizophrenia functional outcomes
Harris and Rempfer (2020). 30	Self-evaluation accuracy in schizophrenia	Not Reported	Validated in schizophrenia  rehabilitation
Faustino et al. (2021). 33	MSAS	0.88 (total scale);  subscales = 0.73–0.84	Validated in the Portuguese population
Pedone et al. (2017). 36	MSAS	0.72–0.87	Four-factor model validated
Pellecchia et al. (2015). 36	MAI	0.79–0.91	Validated in a clinical outpatient population
Popolo et al. (2017). 38	MAS-A, MCQ-30, and BPRS	0.72–0.93	Validated in clinical and non-clinical populations
Raffard et al. (2020). 39	SSTICS	0.86	Validated for cognitive complaints in schizophrenia
Wright et al. (2019). 41	SDM questionnaire, MAI, UCSD performance-based skills assessment (UPSA), time-use survey, PANSS	0.69–0.94	Validated in FEP patients and HC
Wright et al. (2019). 42	MAI, UPSA, PANSS, time-use survey	0.69–0.94	Validated in a FEP population (longitudinal study with three-year follow-up)
Wright et al. (2020). 43	MAI, UPSA, PANSS, time-use survey, IQ assessment (WASI-II)	0.69–0.94	Validated in an FEP population

* MAS: Metacognition Assessment Scale, MAS-A: Metacognition Assessment Scale–Abbreviated, BCIS: Beck Cognitive Insight Scale, CBQp: Cognitive Bias Questionnaire for Psychosis, PSYRATS: Psychotic Symptoms Rating Scale, MAQ: Metacognitive Ability Questionnaire, CAI: Cognitive Assessment Inventory, BaPS: Beliefs About Paranoia Scale, CAS-1: Cognitive–Attentional Syndrome questionnaire, MSAS: Metacognitive Self-Assessment Scale, MAI: Metacognition Assessment Interview, MCQ: Metacognitions Questionnaire, BPRS: Brief Psychiatric Rating Scale, SSTICS: Subjective Scale To Investigate Cognition In Schizophrenia, SDM: Self-defining memories, UPSA: University of California, San Diego (UCSD) performance-based skills assessment (UPSA), PANSS: Positive and Negative Syndrome Scale, WASI-II: Wechsler Abbreviated Scale of Intelligence, Second Edition, FEP: First-episode psychosis.

The metacognitive functioning in the psychopathology category encompasses instruments that assess cognitive insight, self-reflection, cognitive biases, dysfunctional metacognitive beliefs, and the accuracy of self-evaluation in clinical populations. Examples include the BCIS, the Cognitive Bias Questionnaire for Psychosis (CBQp), the Metacognitive Ability Questionnaire (MAQ), the Cognitive Assessment Inventory (CAI), and performance-informed self-assessment tools such as the Wisconsin Card Sorting Test (WCST), used to assess metacognitive accuracy. These are listed in Table 3 and are reported in the studies summarized in Table 2.

Table 2.

Characteristics of the Studies.

Study	Population (Sample)	Relevance for Utilization in the Schizophrenia Population	Insights	Focus
Lysaker and Dimaggio (2014). 6	Individuals with schizophrenia.	Highly relevant as it emphasizes metacognitive impairments as a core feature of schizophrenia, affecting recovery and psychosocial functioning.	Schizophrenia involves deficits in metacognition, particularly in forming integrated self-representations and understanding others. These impairments hinder coping with psychosocial challenges. The study suggests that interventions should go beyond symptom management to target metacognitive rehabilitation, enabling individuals to rebuild complex self- and interpersonal narratives necessary for recovery.	Metacognitive deficits in schizophrenia and the need for interventions targeting metacognitive rehabilitation to support recovery.
Lysaker et al. (2019). 7	Individuals diagnosed with schizophrenia across various clinical presentations (case studies, pilot trials, randomized trials).	Highly relevant, presenting an integrative therapy explicitly targeting metacognitive deficits that impede recovery in schizophrenia, aiming to enhance metacognitive reflection and insight for improved self-management and psychosocial functioning.	Metacognitive deficits significantly interfere with patients’ ability to make sense of their personal and psychosocial challenges. MERIT, by enhancing metacognitive abilities, supports the development of a more coherent and integrated self-narrative, increasing personal agency and self-management. Evidence suggests that MERIT is acceptable and effective in promoting recovery, reducing negative symptoms, and improving overall psychosocial outcomes by enhancing metacognitive abilities.	Development and application of MERIT for enhancing metacognition and promoting recovery in schizophrenia.
Vohs et al. (2014). 9	160 chronic schizophrenia patients (inpatients from Guangzhou Brain Hospital) and 80 healthy controls (HC).	Highly relevant as it provides evidence of immune system dysregulation in schizophrenia, supporting theories linking inflammation and psychopathology.	Serum TNF-α, IL-6, and IL-18 levels were significantly elevated in schizophrenia patients compared to HCs. Findings support the “macrophage T-lymphocyte” hypothesis, suggesting that cytokine-mediated immune responses contribute to schizophrenia pathophysiology. No significant associations were found between cytokine levels and age, gender, smoking, alcohol use, illness duration, or antipsychotic dose.	Inflammatory cytokines (TNF-α, IL-6, IL-18) and their role in schizophrenia pathophysiology.
Luther et al. (2020). 13	56 participants diagnosed with schizophrenia spectrum disorders.	Highly relevant, as it addresses discrepancies between subjective and objective measures of motivation in schizophrenia and identifies metacognition as a crucial moderating factor.	Metacognition significantly moderated the relationship between self-reported and clinician-rated motivation: These measures aligned closely only when metacognition was relatively high. Neither clinical insight nor neurocognition moderated this relationship, highlighting metacognition’s unique role. Using a metacognitive approach in assessments and interventions may enhance congruence between self-perceived and observed motivation in schizophrenia.	The moderating role of metacognition in aligning self-reported and clinician-rated motivation in schizophrenia.
Mishara et al. (2014). 14	Schizophrenia population.	Highly relevant, as it presents the MAS-A as an effective tool for quantitatively assessing self-disturbances (Ichstörungen), a central phenomenological feature linked to impaired sense of self and interaction with others in schizophrenia.	Self-disturbances (Ichstörungen), historically central to schizophrenia, are conceptualized phenomenologically as disturbances in relationships to self and others. The MAS-A demonstrates that patients with schizophrenia produce narratives reflecting reduced capacity for integrating thoughts, emotions, and experiences into coherent self-narratives, resulting in fragmented personal narratives and impaired social interactions. Quantitative assessment of self-disturbances using MAS-A contributes to understanding recovery trajectories and psychosocial outcomes.	Phenomenological understanding and quantitative assessment of self-disturbances (Ichstörungen) and metacognitive impairments in schizophrenia.
James et al. (2016). 15	66 individuals diagnosed with schizophrenia or schizoaffective disorder (primarily middle-aged males).	Highly relevant as it examines the interaction between metacognition and self-appraisal—two key cognitive constructs—in influencing social functioning deficits commonly observed in schizophrenia.	Higher metacognitive capacity significantly moderates the relationship between self-appraisal and social functioning. Participants with higher metacognition and more positive self-appraisal showed better social functioning, independent of psychopathology, neurocognition, or social cognition deficits. Suggests interventions to improve social outcomes in schizophrenia should target both metacognitive capacity and self-appraisal simultaneously.	Interaction of metacognition and self-appraisal in influencing social functioning in schizophrenia.
Jones et al. (2020). 16	Individuals diagnosed with schizophrenia and HC.	Highly relevant, directly addressing deficits in self-assessment, social cognitive functioning, and overconfidence in schizophrenia, which have significant implications for clinical outcomes.	Patients with schizophrenia generally showed reduced overall confidence in social cognitive performance; however, a significant subset displayed extreme overconfidence, performed poorly, and reported the lowest depression. Unlike HC, patients with schizophrenia failed to adjust effort according to task difficulty, and confidence was minimally related to their actual task performance. Overconfidence impacted self-assessment accuracy, particularly without direct feedback.	Self-assessment accuracy, confidence, performance on social cognitive tasks, and their implications in schizophrenia.
Rocca et al. (2021). 17	618 clinically stable outpatients with schizophrenia from 24 centers in Italy.	Highly relevant, as it assesses self-awareness of real-life functioning in schizophrenia, a key factor influencing rehabilitation and treatment planning.	Patients with schizophrenia generally overestimated their real-life functioning compared to caregiver assessments. The strongest predictor of self-assessment accuracy was caregiver ratings, with lower ratings associated with greater overestimation by patients. Avolition and cognitive deficits were associated with more accurate self-evaluations. Findings suggest self-reports can be a valuable clinical tool in stable schizophrenia cases with structured mental health support.	Accuracy of self-reported real-life functioning in schizophrenia and its predictors.
Bröcker et al. (2017). 18	Schizophrenia patients	Reliable tool for metacognitive assessment in schizophrenia contexts.	MAS-A: A reliable tool for metacognitive assessment via narrative analysis.	Metacognitive Functioning in Psychopathology.
Simón-Expósito and Felipe-Castaño (2019). 19	22 patients with schizophrenia (11 in the experimental group receiving MCT, 11 in the control group receiving usual treatment) from two residential rehabilitation centers.	Highly relevant as MCT enhances cognitive flexibility, increases self-reflection, and reduces self-certainty, which are critical for improving insight and reducing delusional conviction in schizophrenia.	MCT led to increased self-reflection and decreased self-certainty, suggesting improved cognitive insight. Statistically significant reductions were observed in positive symptoms, including delusions, hostility, and hallucinatory behavior. The program showed high adherence and applicability in clinical settings, supporting its real-world utility for schizophrenia treatment.	Effectiveness of MCT in improving cognitive insight and reducing positive symptoms in schizophrenia.
Chuang et al. (2021). 20	48 outpatients with schizophrenia from the Department of Psychiatry, Zuoying Branch of Kaohsiung Armed Forces General Hospital, Taiwan.	Highly relevant, as it examines how metacognitive beliefs and cognitive functions influence empathy deficits in schizophrenia, which impact social cognition and interpersonal relationships.	Cognitive self-consciousness (a domain of MCQ-30) was significantly related to perspective-taking. Positive beliefs about worry and resistance were associated with fantasy, whereas negative symptoms and cognitive self-consciousness were associated with lower empathy. Personal distress correlated with cognitive confidence and with deficits in inhibitory control. Findings highlight the need for metacognitive interventions targeting social cognition in schizophrenia.	Relationship between metacognitive beliefs, cognitive impairments, and empathy in schizophrenia.
Erawati et al. (2014). 24	Schizophrenia patients	Assesses cognitive biases and metacognitive abilities in schizophrenia.	Indonesian versions of PSYRATS and CBQp are reliable for metacognitive evaluation.	Metacognitive assessment tools.
Gould et al. (2015). 25	Schizophrenia patients	Predicts real-world functioning based on self-assessment in schizophrenia.	Self-assessment accuracy predicts real-world functioning.	Metacognitive functioning in psychopathology.
Morrison et al. (2015). 26	117 individuals at ultra-high-risk of psychosis from the Early Detection and Intervention Evaluation (EDIE)-2 trial; comparisons made with 45 psychiatric inpatients with paranoid delusions and 318 healthy university students.	Highly relevant as it identifies cognitive and affective predictors of paranoia, distinguishing between persecutory beliefs and the belief that persecution is deserved (poor-me vs. bad-me paranoia).	Negative beliefs about others were associated with paranoia, while negative self-beliefs were related to deservedness. Depression was explicitly linked to paranoia, but not deservedness. Negative metacognitive beliefs about paranoia (e.g., paranoia is uncontrollable) were also significantly correlated with persecutory ideation. Findings suggest cognitive-behavioral interventions should target these specific cognitive and metacognitive patterns to reduce paranoia in high-risk populations.	Predictors of paranoia (persecution vs. deservedness) in individuals at ultra-high-risk of psychosis using metacognitive and affective models.
Murphy et al. (2017). 27	Individuals with paranoia-related beliefs	Links metacognitive beliefs to paranoia severity in schizophrenia.	Positive and negative beliefs about paranoia are linked to suspicion severity.	Paranoia and Metacognition.
Kowalski and Dragan (2019). 28	Community and clinical samples	Measures the psychometric properties of self-reports of patients with cognitive attention syndrome.	CAS-1 is reliable for CAS, limited to non-clinical samples.	Metacognitive assessment tools.
Fischer et al. (2020). 29	Schizophrenia patients	Demonstrates how metacognition improves social functioning in schizophrenia.	Higher metacognition improves social functioning in individuals with schizophrenia symptoms.	Social cognition and metacognition.
Harris and Rempfer (2020). 30	Schizophrenia patients	Highlights the self-evaluation’s role in rehabilitation for schizophrenia.	Self-evaluation accuracy indicates rehabilitation potential.	Social cognition and metacognition.
Craig et al. (2020). 31	Various metacognitive research samples	Highlights limitations of self-reports for schizophrenia studies.	Self-reports are reliable for metacognitive knowledge but limited for complex processes.	Metacognitive assessment tools.
Hochheiser et al. (2020). 1	92 individuals diagnosed with schizophrenia spectrum disorders (schizophrenia and schizoaffective disorder).	Highly relevant as it explores metacognition, mindfulness, and cognitive insight, key cognitive constructs implicated in schizophrenia, and their roles in enhancing self-compassion.	Results indicate that mindfulness and metacognitive awareness of others positively predict higher self-compassion, while cognitive insight is associated with greater negative self-compassion (self-judgment). Metacognition and mindfulness may support positive self-compassion, thus benefiting recovery processes. Cognitive insight may increase self-criticism or negative self-compassion.	Metacognition, mindfulness, cognitive insight, and their relationship with self-compassion in schizophrenia.
Davies et al. (2017). 32	80 individuals diagnosed with FEP from EIP services in Sussex, UK.	Highly relevant as it identifies metacognition as a key mediator between neurocognitive abilities and real-world functioning in FEP, suggesting that interventions targeting metacognition could enhance functional recovery.	Metacognition partially mediated the relationship between neurocognition and functional capacity and fully mediated the relationship between functional capacity and real-world function (social and occupational outcomes). This suggests that raw cognitive ability alone is insufficient for real-world functioning and that metacognitive ability is critical for translating cognitive skills into practical applications.	The role of metacognition as a mediator between neurocognition, functional capacity, and real-world outcomes in FEP.
Faustino et al. (2021). 33	Non-clinical population	Explores the correlations between metacognition and cognitive fusion in schizophrenia.	MSAS is reliable in the Portuguese population, in correlation with cognitive fusion.	Metacognitive functioning in psychopathology.
Kilicoglu et al. (2024). 34	Small sample; no psychiatric comorbidity data	Links mastery and self-reflectivity to social functioning in schizophrenia.	Mastery is linked to social functioning in schizophrenia, and high self-reflectivity is linked to poor self-reported social functioning.	Metacognitive functioning in psychopathology.
Martiadis et al. (2023). 35	Individuals with schizophrenia and related psychoses.	Highly relevant, as it reviews and provides practical guidance on multiple validated tools for assessing metacognitive deficits in schizophrenia, which are essential for targeted clinical assessment and research.	Metacognitive deficits in schizophrenia are crucially related to the severity of clinical symptoms, especially negative symptoms and disorganization, significantly impacting functional outcomes. Reliable assessment of metacognitive capacity using validated instruments (e.g., MAS-A, BCIS, MCQ-30) can inform tailored interventions, track therapeutic progress, and enhance understanding of schizophrenia’s complex symptomatology.	Overview and evaluation of psychometric instruments designed to measure metacognitive abilities in schizophrenia for clinical and research applications.
Pedone et al. (2017). 36	Non-clinical population	Evaluates metacognitive abilities; limited clinical validation.	MSAS is reliable; further validation is needed for clinical populations.	Metacognitive assessment tools.
Pellecchia et al. (2015). 37	306 outpatients from an Italian private clinical setting, excluding individuals with schizophrenia, active psychotic disorders, or neurological conditions.	Relevant, as metacognition impairments are a core feature of schizophrenia. Findings can guide metacognition-based interventions to improve self-reflection, understanding of others, and psychosocial functioning.	MAI exhibited strong psychometric properties, confirming two-factor (self and other) and four-factor (monitoring, integration, differentiation, and decentration) models. The self-domain correlated with alexithymia, while the other domain correlated with interpersonal difficulties. Findings support MAI as a valuable tool for assessing metacognitive impairments relevant to schizophrenia and other psychopathologies.	Validation and application of the MAI to assess metacognition across psychopathologies, with potential relevance to schizophrenia treatment and intervention.
Popolo et al. (2017). 38	72 participants: 26 with schizophrenia, 23 with bipolar disorder, 23 HC.	Highly relevant, as it identifies metacognitive deficits in schizophrenia compared to bipolar disorder and HC, linking them to negative symptoms  and psychosocial functioning.	Schizophrenia patients had significantly lower metacognitive abilities (MAS-A) than both bipolar disorder and HC, but no group differences were found for maladaptive metacognitive beliefs (MCQ-30). Negative symptoms correlated with lower metacognition, highlighting the role of metacognitive impairments in functional outcomes. The bipolar disorder group had milder deficits, suggesting a distinct metacognitive profile compared to schizophrenia.	Differences in metacognitive abilities between schizophrenia, bipolar disorder, and HC, and their relationship with negative symptoms.
Raffard et al. (2020). 39	Individuals with schizophrenia and HC	Highly relevant as it specifically assesses cognitive complaints and self-awareness in schizophrenia, with demonstrated ability to detect differences between patients and controls.	A significant proportion of schizophrenia patients can accurately assess their cognitive abilities. Psychoaffective factors influence cognitive complaints.	Metacognitive awareness and self-evaluation of cognitive functioning.
Vita et al. (2022). 40	Subjects with schizophrenia; FEP patients; clinical high-risk individuals; HC	Gold standard for cognitive assessment in schizophrenia with strong validation data and direct relevance to functional outcomes.	Reveals a comprehensive cognitive profile that helps predict functional capacity and real-world functioning in schizophrenia patients.	Explicitly designed to assess cognitive impairment in schizophrenia and measure response to cognitive enhancement interventions.
Wright et al. (2019). 41	71 individuals with  FEP and 57 HC.	Highly relevant as it demonstrates that SDMs influence functional outcomes in FEP, independent of metacognition and neurocognition.	Individuals with FEP reported less integrated and more negative SDMs than HC. SDM specificity was associated with better engagement in structured activities. Memory specificity partially mediated the relationship between neurocognition and functional outcomes, suggesting that structured interventions focusing on autobiographical memory recall could improve recovery.	The impact of SDMs on functional outcomes in FEP, independent of metacognition.
Wright et al. (2019). 42	80 individuals with FEP, with follow-up data collected from 26 participants over three years.	Highly relevant, as it demonstrates that metacognition is the key predictor of functional improvement in FEP, independent of neurocognition, functional capacity, and negative symptoms.	Metacognitive ability at baseline significantly predicted functional improvement at three-year follow-up, whereas neurocognition, functional capacity, and negative symptoms did not. Individuals with higher metacognitive ability engaged in more structured activities over time, supporting the need for metacognitive interventions in early psychosis.	The longitudinal impact of metacognition on functional outcomes in FEP, emphasizing early intervention.
Wright et al. (2020). 43	52 individuals with FEP were recruited from an EIP service in the UK.	Highly relevant as it identifies metacognition as a key factor in employment outcomes, suggesting that metacognitive ability may be more important than IQ for job engagement.	Metacognition significantly predicted employment status, independent of IQ and functional capacity. Individuals with higher metacognition were more likely to be employed, even after controlling for IQ. However, neither metacognition nor IQ predicted the number of hours worked among those who used them. Findings highlight the importance of MCT interventions to enhance employment outcomes.	The role of metacognition and cognitive functioning in predicting employment outcomes in FEP.

MERIT: Metacognitive Reflection and Insight Therapy, MCT: Metacognitive Training, MAS: Metacognition Assessment Scale, MCQ: Multiple Choice Questions, CAS: Cognitive–Attentional Syndrome, EIP: Early Intervention in Psychosis, MAI: Metacognition Assessment Interview, FEP: First-episode psychosis, SDMs: Self-defining memories.

The social cognition and metacognition category includes tools for evaluating how metacognition shapes interpersonal behavior, social functioning, ToM, and self–other understanding. Representative measures include the Social Cognition and Object Relations Scale (SCORS), the Work Behavior Inventory, the Hinting Task, and the metacognitive components within narrative-based MAS scoring. These applications are reflected in studies such as James et al. (2016), ¹⁵ Fischer et al. (2020), ²⁹ and Wright et al. (2019–2020),^42,43 which are summarized in Table 2 and whose corresponding instruments are listed in Table 3.

The paranoia and metacognition category includes instruments assessing metacognitive beliefs associated with paranoia, suspiciousness, and threat anticipation. Key examples are the Beliefs about Paranoia Scale (BaPS), relevant subscales of the MCQ-30 (e.g., negative beliefs about thoughts, cognitive confidence), and the Psychotic Symptoms Rating Scale (PSYRATS), delusion subscale. These instruments appear in paranoia-related studies listed in Tables 2 and 3.

Self-report Measures of Metacognition

Self-report measures are widely used to assess metacognition in both clinical and non-clinical populations, offering insight into individuals’ self-reflective and cognitive processes. Figure 2 shows the number of studies that employed self- report measures. The major categories of these instruments, as identified in this review, include metacognition assessment tools, psychiatric insight and cognitive belief scales, symptom and functional outcome measures, and self-report or interview-based assessments. Tools such as the MAS and its variants evaluate dimensions such as self-reflectivity and understanding of one’s own and others’ minds. At the same time, the MCQ-30 assesses beliefs about cognitive processes, including confidence and control over thoughts. The MSAS examines monitoring, differentiation, and mastery over cognitive processes. In psychiatric contexts, the BCIS is frequently used to measure self- reflectiveness and self-certainty, and the BaPS targets positive and negative beliefs associated with paranoia. Symptom and functional outcome measures, such as the Positive and Negative Syndrome Scale (PANSS) and the CAI, are employed to evaluate psychiatric symptom severity and relate these outcomes to metacognitive capacities. Additionally, self-report questionnaires, such as the CAS-1, and semi-structured interviews, such as the MAI, facilitate self-assessment of cognitive beliefs and strategies in real-life contexts. This diversity of self-report tools underscores the methodological breadth within metacognitive research and supports their broad application for understanding cognitive and functional outcomes in schizophrenia and related disorders.

Figure 2. Self-report Measures vs. Number of Studies.

Review of Eligible Studies

To provide a structured synthesis, the reviewed studies were categorized based on their primary focus: (a) Metacognitive assessment tools and psychometric validation, (b) metacognition and symptom severity, (c) metacognition and functional outcomes, (d) metacognition and treatment response, and (e) theoretical and conceptual developments in metacognition research. This approach enables a comprehensive analysis of the relationships among metacognition, cognitive insight, symptomatology, and clinical applications.

Metacognitive Assessment Tools and Psychometric Validation

Validation of self-report measures is central to metacognition research in schizophrenia. Although earlier and longer forms of metacognitive measures, such as the MCQ-60 and MCQ-65, exist, our search identified no eligible schizophrenia studies employing these versions. Instead, the literature predominantly uses the shorter MCQ-30, which has been validated across multiple schizophrenia samples and remains the most commonly adopted version in clinical research. The BCIS consistently demonstrates robust psychometric properties, with studies reporting Cronbach’s alpha values ranging from 0.56 to 0.80, supporting its reliability for assessing self-reflectiveness and self-certainty. ¹⁹ The MAS and its variants similarly show strong reliability, with internal consistency coefficients ranging between 0.65 and 0.86,^22,23 while the MCQ-30 demonstrates validated factor structures and subscale reliabilities typically falling between 0.70 and 0.90, indicating stable measurement of dysfunctional metacognitive beliefs. ²⁰ Cross-cultural studies further confirm the reliability of translated measures, with Indonesian versions of the PSYRATS, CBQp, and MAQ reporting Cronbach’s alpha values around 0.76, ²⁴ and the German MAS-A showing high inter-rater reliability with coefficients up to 0.86. ¹⁸ Regarding self-assessment accuracy, research highlights that both underestimation and overestimation of cognitive abilities predict real-world functioning, ²⁵ and that schizophrenia patients often overestimate their capacities compared to caregiver assessments. ¹⁷ Overall, these findings support the value of self-report tools in schizophrenia research but also underscore the need for cautious interpretation due to potential insight-related biases in this population.

Metacognition and Symptom Severity

Numerous studies have demonstrated that metacognitive deficits are closely linked to the severity of psychiatric symptoms in schizophrenia. For instance, research using the BaPS has shown that negative metacognitive beliefs about paranoia are moderately associated with greater distress and emotional burden. In a clinical sample, higher BaPS negative-belief scores correlated with distress from persecutory beliefs on the PSYRATS at r = 0.38 and with PANSS anxiety at r = 0.42, while survival (protective) beliefs also showed smaller but significant associations with distress and suspiciousness.^26,27 In an ultra-high-risk cohort, multilevel models indicated that both negative and survival beliefs about paranoia significantly predicted paranoia severity (e.g., BaPS negative beliefs: B = 0.037, SE = 0.011, p < .001), together explaining around 28% of the between- person variance in paranoia ratings; paranoia severity was also moderately correlated with perceived deservedness (r = 0.33, p < .001). ²⁶ The CAS-1 has demonstrated good internal consistency (Cronbach’s α = 0.85), and a regression model including rumination and metacognitive belief scales accounted for 48% of the variance in CAS-1 scores (R² = 0.48), underscoring the central role of perseverative thinking, worry, and cognitive rigidity in maintaining distress. ²⁸ Across BCIS studies, higher self-certainty has consistently been linked to more severe cognitive or disorganized symptoms and poorer insight. At the same time, greater self-reflectiveness is associated with better functional outcomes and emotional adjustment. ⁴ In line with these findings, longitudinal work shows that reduced metacognitive self-awareness is associated with poorer insight and lower treatment engagement over time, both in first-episode and prolonged psychosis samples.^1,9

However, some included studies also report null or mixed findings. For example, Popolo et al. (2017) ³⁸ found no significant group differences in maladaptive metacognitive beliefs measured by the MCQ-30 between individuals with schizophrenia, bipolar disorder, and HC, suggesting that dysfunctional metacognitive beliefs may not be uniquely elevated in schizophrenia. Similarly, Jones et al. (2020) ¹⁶ observed that confidence–performance relationships were weaker and more inconsistent in schizophrenia, with some patients showing “extreme overconfidence” despite poor performance, indicating that metacognitive accuracy does not uniformly track symptom severity across all individuals. These patterns highlight that metacognitive impairment is heterogeneous, and specific domains, particularly cognitive confidence and belief inflexibility, may not always correlate strongly with symptom metrics.

Collectively, these findings confirm that metacognitive dysfunction plays a significant role in symptom severity, particularly in paranoia, delusions, and deficits in cognitive insight, highlighting its importance as a clinical target in schizophrenia.

Metacognition and Functional Outcomes

A substantial body of research underscores the relationship between metacognitive capacity and real-world functional outcomes in schizophrenia. For example, James et al. (2016) found that, after controlling for overall symptom severity, higher metacognitive capacity (MAS-A total) was moderately associated with better social functioning: Interpersonal relations (r = 0.39, p < .001) and intrapsychic foundations (r = 0.45, p < .001), while a composite self-appraisal factor also correlated with intrapsychic foundations (r = 0.28, p < .05). A regression model including psychopathology (PANSS total), metacognition, and self-appraisal explained 49% of the variance in intrapsychic foundations (R² = 0.49), and Analysis of Covariance (ANCOVA) showed that patients with both higher metacognitive capacity and less dysfunctional self-appraisal had significantly higher intrapsychic foundations scores than all other groups, even after controlling for positive and negative symptoms. ¹⁵ Complementing this, Fischer et al. (2020) reported that self-reported interpersonal behavior on the Social Functioning Scale was positively related to metacognitive decentration and overall MAS-A scores (r = 0.31 for both, p < .01). In contrast, higher PANSS total scores were strongly associated with poorer interpersonal behavior (r = −0.56, p < .001). Moreover, metacognitive capacity significantly moderated the impact of symptoms on interpersonal behavior: An interaction term between PANSS total and MAS-A total was significant (b = −0.071, SE = 0.03, p = .019), and lower symptom levels predicted better interpersonal behavior only when MAS-A scores exceeded 6.13, with this moderation effect remaining after controlling for executive function. ²⁹ Extending these findings to rehabilitation outcomes, Harris and Rempfer (2020) showed that distinct profiles of self-evaluation, as a metacognitive skill, were differentially associated with indicators of rehabilitation potential, suggesting that individuals who demonstrate more adaptive or realistic self-evaluation may have greater capacity to benefit from psychosocial and vocational interventions. Clinically, this distinction indicates that self-evaluation profiles can guide intervention planning: Individuals who underestimate deficits may benefit most from goal-oriented rehabilitation and skills training, while those who overestimate their abilities may require targeted metacognitive interventions, such as feedback-enhanced therapy or insight-oriented work, to improve engagement and treatment responsiveness. By integrating self-evaluation patterns into clinical decision-making, practitioners can tailor rehabilitation strategies more effectively to patient needs. Collectively, these results indicate that metacognitive capacity and self-evaluative processes are closely tied to social functioning, perceived quality of life, and rehabilitation potential in schizophrenia, reinforcing metacognition as a key target for interventions to improve everyday outcomes. ³⁰ Although overall patterns were consistent, some null findings were also reported. James et al. (2016) likewise noted that specific dysfunctional self-appraisal components were not significantly associated with social functioning domains when psychopathology was entered into the model, suggesting partial rather than uniform effects across metacognitive dimensions. ¹⁵ In Fischer et al. (2020), several MAS-A subcomponents (including mastery and some self-reflectivity items) did not show significant correlations with interpersonal behavior after symptom severity was controlled, indicating that not all facets of metacognition contribute equally to social functioning. ²⁹

Metacognition and Treatment Response

Research shows that metacognitive abilities significantly influence treatment outcomes in schizophrenia. Furthermore, these enhancements in mindfulness and metacognition were associated with increased self-compassion and reduced self-criticism, mechanisms known to facilitate engagement in Cognitive Behavioral Therapy (CBT) and Metacognitive Training (MCT), particularly among individuals with prominent paranoid ideation. ³¹ Similarly, in a cross-sectional study of 92 participants with schizophrenia spectrum disorders, Hochheiser et al. (2020) found that metacognitive capacity, particularly awareness of others, significantly predicted positive self-compassion (β = 0.26, p < .001), while mindfulness accounted for an additional 11% of variance in self-compassion (Step 2: R² change = 0.11, p < .001). These findings indicate that greater dispositional mindfulness and metacognitive capacity are independently linked to better emotional self-regulation and may support therapeutic gains. ¹ Collectively, these results highlight that targeted therapeutic approaches such as CBT, MCT, and mindfulness-based interventions can produce measurable improvements in metacognitive functioning, thereby strengthening psychological and pharmacological treatment response in schizophrenia.

Theoretical and Conceptual Developments in Metacognition Research

Several studies have contributed critical theoretical perspectives on the role of metacognition in schizophrenia. For example, Mishara et al. ¹⁴ demonstrated that disturbances in self-experience, evident as fragmented self-narratives, underscore the importance of metacognition for self-identity and coherence. Additionally, Lysaker et al. (2019), ⁷ introduced Metacognitive Reflection and Insight Therapy, highlighting the value of tailored, patient-centered interventions for metacognitive deficits. These works connect metacognition to the genetic, neurological, and experiential aspects of schizophrenia, emphasizing its central role in symptom severity and functional outcomes. They also underscore the need for future longitudinal, cross-cultural, and neurobiological research to refine assessment and intervention strategies further. The characteristics of the key studies, including the analyses performed, insights, and categorization by study focus, are provided in Table 2.

Table 3 summarizes various assessment measures used in studies on metacognition, cognitive insight, and related psychological constructs in schizophrenia. It includes the purpose of each measure and references the studies that utilized them.

Psychometric Properties

The psychometric properties of self- report measures of metacognition in schizophrenia have been thoroughly investigated, focusing primarily on reliability, validity, and clinical applicability. Most studies report high internal consistency, typically using Cronbach’s alpha values of 0.70–0.95 for widely used instruments such as the MAS and the BCIS, indicating robust reliability. Some instruments, such as the MSAS, have been examined for test–retest reliability, confirming stability over time; however, such longitudinal assessments are less common, highlighting a gap in the literature.

Validity has also been a key area of focus. Factor analyses have supported the multidimensional structure of measures such as the MCQ-30 and the CAS-1, thereby reinforcing their construct validity. Strong correlations between tools such as the BaPS and related constructs, including paranoia and anxiety, demonstrate convergent validity. Discriminant validity, in contrast, is less frequently addressed, underscoring the need for further work to establish that these measures do not unduly overlap with unrelated constructs. Predictive validity is supported by findings that self-assessment accuracy on measures such as the CAI predicts real-world functional outcomes, underscoring the clinical significance of these measures.

Additionally, several studies have validated culturally adapted versions of these tools, such as the Indonesian PSYRATS, confirming that translated scales retain satisfactory reliability and validity. Nevertheless, comprehensive cross-cultural validation and research on sensitivity to change remain limited. To maximize the utility of these measures, future studies should emphasize longitudinal, cross-cultural, and intervention-related psychometric evaluations. Table 4 presents the psychometric properties of self-report measures of metacognition.

Clinical Utility

Metacognitive assessment tools have demonstrated significant clinical utility in the diagnosis, monitoring, and treatment planning for psychiatric conditions, particularly schizophrenia. Their usefulness is reinforced by the strong psychometric properties summarized earlier, including internal consistency values ranging from 0.70 to 0.95 across tools such as the MAS, BCIS, MCQ-30, MSAS, and CAS-1, which provide clinicians with confidence that observed changes in metacognition reflect true clinical shifts rather than measurement error.

Widely used instruments such as the PANSS and the PSYRATS help gauge symptom severity. In contrast, integrating metacognitive measures, such as the MAS, helps contextualize symptom severity within the broader framework of metacognitive deficits, including impaired self-reflectivity, reduced cognitive confidence, and difficulties understanding others’ perspectives. Linking deficits to reliable measurement allows clinicians to determine whether poor functioning reflects symptom-driven impairment or underlying metacognitive dysfunction, thereby directly guiding treatment focus.

The BCIS is especially valuable for tracking changes in self-reflectiveness and self-certainty during interventions aimed at improving insight, and its established reliability across clinical samples supports its use in longitudinal monitoring. Similarly, tools such as the BaPS and CAS-1 inform treatment planning by identifying maladaptive beliefs about paranoia, rumination, and worry, all of which are core targets in CBT and MCT.

Because these instruments reliably quantify specific metacognitive deficits, such as low self-reflectivity, poor mastery, or cognitive inflexibility, they help clinicians select appropriate interventions, determine readiness for rehabilitation, and monitor clinically meaningful improvement. Measures such as the CAI and MSAS, which have demonstrated strong validity in predicting vocational and interpersonal functioning, further support individualized rehabilitation and resource allocation.

Despite their value, these tools rely heavily on self-report or narrative performance, which can be affected by poor insight, cognitive deficits, or symptom fluctuation in schizophrenia. Additionally, specific measures (e.g., MAS-A, MAI) require specialized training and substantial scoring time, limiting their scalability in routine clinical settings.

Final, culturally adapted versions of instruments such as the Indonesian CBQp, PSYRATS, and MAQ ensure that assessment accuracy is maintained across settings, strengthening global clinical applicability. Together, the combination of strong psychometric support and well-characterized metacognitive deficits underscores why metacognitive assessment tools meaningfully enhance diagnostic precision, intervention planning, and treatment monitoring in schizophrenia.

Thematic Analysis of Measure Content

Thematic analysis of metacognitive assessment measures in schizophrenia reveals several key themes regarding instrument types and their clinical applications.

A primary theme emerging from this systematic thematic analysis is the emphasis on psychometric robustness. Specific subdomains, such as self-reflectivity and mastery in the MAS and self-reflectiveness and self-certainty in the BCIS, were most consistently validated for internal consistency, test–retest reliability, and factor structure, indicating stable measurement across studies.

Another central theme is the integration of metacognitive assessments with symptom severity scales such as the PANSS, allowing clinicians to contextualize deficits in self-reflection, decentration, and cognitive confidence within broader psychiatric symptomatology. Measures focusing on social cognition, including the MAS (Decentration subscale) and SCORS, also highlight how difficulties in perspective-taking and understanding others are associated with social withdrawal and impaired interpersonal functioning.

Self-reflection and belief evaluation were commonly targeted domains, particularly through the BCIS (self- certainty) and BaPS (negative beliefs), which capture distortions that drive paranoia and cognitive inflexibility. Similarly, instruments assessing cognitive adaptability, such as the WCST (set- shifting) and CAI (self-monitoring), inform predictions about rehabilitation readiness and independent living.

However, the reliability and clinical applicability of these measures may be influenced by factors such as medication status, symptom severity, co-morbid depression or anxiety, and illness duration, all of which can affect insight, cognitive load, and response accuracy.

In summary, the reviewed studies show that specific metacognitive domains, particularly self-reflectivity, self-certainty, decentration, and cognitive flexibility, drive the strongest clinical associations. As this thematic synthesis was systematic but based on the available literature, some domains (e.g., self-reflection) are more frequently represented than others, underscoring the need for future work to develop balanced and ecologically valid assessment frameworks.

Relationships Between Metacognition and Clinical Variables

The relationship between metacognition and clinical variables, such as symptom severity, insight, and functional outcomes, has been a focal point in the studies reviewed. Across these studies, metacognitive deficits are frequently linked to the severity of psychiatric symptoms, particularly in disorders such as schizophrenia. For instance, the PANSS is commonly used alongside metacognitive measures, such as the MAS, to examine the relationship between cognitive insight and symptomatology. Findings suggest that lower levels of metacognitive ability, such as impaired self-reflectivity and mastery, are associated with greater symptom severity, including both positive (e.g., hallucinations, delusions) and negative (e.g., social withdrawal, apathy) symptoms.

Moreover, cognitive insight, as assessed by the BCIS, correlates with treatment outcomes and rehabilitation potential. Studies indicate that patients with higher self-reflectiveness and lower self-certainty often have better insight into their conditions, which can positively influence their responsiveness to therapeutic interventions. In contrast, high self-certainty, a form of cognitive rigidity, may hinder treatment progress, as it reflects overconfidence in distorted beliefs.

Functional outcomes, such as social and vocational functioning, are also closely related to metacognitive abilities. Tools such as SCORS and CAI indicate that improved metacognitive skills, including understanding one’s own and others’ minds, predict better interpersonal relationships and real-world success. The reviewed studies consistently show that deficits in metacognition contribute to poor social functioning, reinforcing the idea that enhancing metacognitive abilities could improve quality of life and clinical outcomes for individuals with psychiatric conditions.

Discussion

Key Findings

This systematic review underscores the central role of metacognition in understanding, assessing, and treating schizophrenia. Using a systematic thematic analysis, four core domains were identified: Metacognitive assessment tools, metacognitive functioning in psychopathology, social cognition and metacognition, and paranoia and metacognition. Rather than restating earlier findings, this section interprets how these domains collectively inform clinical practice and future research.

A key takeaway is that specific metacognitive subdomains, particularly self-reflectivity, mastery, decentration, and self-certainty, consistently drive the most clinically meaningful outcomes. Their strong psychometric support, including high internal consistency for tools such as the MAS-A, BCIS, MSAS, and CAS-1, reinforces their utility in distinguishing between symptom-driven impairment and underlying cognitive–metacognitive dysfunction. At the same time, the review highlights areas requiring further strengthening, including longitudinal validation and cultural adaptation, to ensure measurement stability across illness phases and diverse populations.

The findings suggest that metacognitive tools do more than quantify cognitive deficits; they help clinicians understand how individuals interpret symptoms, relate to others, and evaluate their capabilities, allowing for more targeted therapeutic planning. For example, BCIS self-certainty and BaPS negative beliefs can identify cognitive distortions relevant to paranoia and treatment resistance. At the same time, MAS subscales help differentiate whether poor functioning stems from limited self-reflectivity, impaired perspective-taking, or rigid cognitive styles. These distinctions have actionable therapeutic implications, guiding treatment allocation in CBT, MCT, psychosocial rehabilitation, and insight-oriented interventions.

Beyond symptoms, metacognitive capacities strongly influence real-world outcomes. Higher self-reflectivity and cognitive flexibility are consistently associated with better social functioning, treatment engagement, and vocational performance, whereas deficits in decentration or self- appraisal predict isolation, poor insight, and inconsistent treatment adherence.

Importantly, these relationships are not uniform; factors such as medication status, comorbidities, illness duration, and acute symptom load may alter the reliability or expression of metacognitive abilities, underscoring the need for contextual interpretation of assessment results.

Overall, the synthesis demonstrates that metacognitive assessments are most powerful when integrated with symptom measures and functional evaluations. Their value lies not only in their measurement accuracy but also in their role in shaping a formulation-driven, personalized approach to schizophrenia care. Future work should continue to refine domain-specific tools, broaden cross-cultural validation, and develop ecologically valid assessments that capture the dynamic, context-sensitive nature of metacognition in everyday life.

Strengths of Existing Measures

The systematic review reveals several key advantages of the existing measures used to assess metacognition in psychiatric and non-clinical populations.

High Reliability and Validity

Many metacognitive tools demonstrate strong psychometric properties, particularly internal consistency and construct validity. Measures such as the MAS and the BCIS frequently report Cronbach’s alpha values above 0.70, indicating reliable internal consistency. Factor analyses across studies confirm that these tools capture distinct metacognition dimensions, thereby ensuring their validity for both research and clinical applications.

Utility in Clinical Diagnosis and Symptom Tracking

These measures effectively support the diagnosis of psychiatric conditions and tracking symptom severity. For example, integrating the PANSS with metacognitive tools provides a comprehensive view of patients’ cognitive insights and symptom profiles. This diagnostic utility allows clinicians to tailor treatment plans based on metacognitive profiles, making interventions more targeted and potentially more effective.

Insight into Cognitive and Social Functioning

Metacognitive measures provide valuable insights into patients’ cognitive and social functioning. Tools such as SCORS and CAI reveal how metacognitive abilities affect social interactions, helping clinicians identify and address deficits that hinder interpersonal relationships. This ability to predict functional outcomes is a significant advantage, as it extends the utility of these measures beyond symptom assessment to practical, real-world applications.

Applicability to Diverse Populations

Many of these tools have been successfully adapted across diverse cultural contexts, enhancing their versatility. Studies validating translated versions, such as the Indonesian PSYRATS, indicate that these measures retain their reliability and validity across cultures. This adaptability ensures that metacognitive assessments can be utilized in diverse clinical settings, supporting global mental health initiatives.

Although many tools, such as the MAI and CAS-1, are relatively easy to administer, several metacognitive assessments, including narrative-based instruments such as the MAS-A and structured interviews such as the MAI, require trained raters and substantial scoring time, which may limit their adoption in fast-paced clinical settings. Brief, self-report versions with simpler scoring procedures may therefore be more feasible for routine practice.

The existing metacognitive measures are not only reliable and valid but also versatile and clinically useful. They provide detailed insights into cognitive and social functioning, are adaptable to diverse populations, and are user-friendly, making them valuable tools for mental health professionals in various settings.

Limitations of Existing Measures

First, the heavy reliance on self-report and narrative-based assessments introduces potential biases, particularly in individuals with impaired insight or active symptoms; for example, Rocca et al. (2021) ¹⁷ found that many patients overestimated their real-life functioning compared to caregiver ratings, indicating vulnerability to self- report inaccuracies. Second, although some instruments, such as the BCIS and MCQ-30, have been translated and validated in non- English contexts, studies such as Erawati et al. (2014) ²⁴ show that cultural adaptations (e.g., Indonesian CBQp and PSYRATS) still exhibit limited cross-validation, underscoring the need for more rigorous multicultural evaluation. Third, the evidence base is dominated by cross-sectional designs, including many MAS-A, BCIS, and MCQ-30 studies, which restrict conclusions about long-term stability and predictive validity; only a few studies, such as Wright et al. (2019), ⁴² offer longitudinal insight into metacognitive change over time. Final, conceptual overlap among metacognition, insight, and social cognition complicates interpretation: For instance, Popolo et al. (2017) ³⁸ found no group differences in MCQ-30 maladaptive beliefs between schizophrenia, bipolar disorder, and HC, highlighting the difficulty of isolating metacognition from related constructs when measures assess overlapping domains.

Implications for Clinical Practice

Tailored Assessments

Clinicians should carefully select self-report measures based on the specific metacognitive domains to be assessed. For example, the MAS-A provides a detailed assessment of self-reflection and ToM, while the BCIS focuses on self-reflectiveness and cognitive distortions. Tailoring assessments to individual patients’ needs will enhance the clinical utility of these tools.

Monitoring Treatment Progress

The demonstrated sensitivity to change of measures such as the MAS-A and BCIS supports their use in monitoring treatment progress. These measures can be used to track changes in metacognitive abilities throughout treatment and to provide valuable feedback to both patients and clinicians.

Integration with Other Assessment Tools

Given the complexity of metacognitive functioning in schizophrenia, a multimodal assessment approach that combines self-report measures, performance-based tasks, and clinician ratings may provide a more comprehensive understanding of patients’ cognitive profiles.

Cultural Adaptations

Clinicians working with diverse populations should select self-report measures that have been appropriately adapted to their patients’ cultural contexts. This will ensure that the measures are valid and relevant to the specific population under study.

Future Directions for Research

Longitudinal Studies

There is a need for more longitudinal research to establish the long-term stability and predictive validity of self-report measures of metacognition in schizophrenia. Future studies should track changes in metacognitive abilities over time and explore how these changes relate to clinical outcomes.

Integration with Neurobiological Research

Self-report measures should be integrated with neurobiological approaches, such as neuroimaging, to better understand the neural underpinnings of metacognitive deficits in schizophrenia. This could provide valuable insights into the brain mechanisms underlying metacognitive impairments and inform the development of targeted interventions.

Development of New Measures

While several robust self-report measures already exist, there remains scope to develop new instruments that address current limitations. Future measures should aim to reduce conceptual overlap with related constructs, enhance cultural adaptability, and capture emerging conceptualizations of metacognition. Notably, several domains remain underrepresented in existing tools, including metacognitive monitoring of emotions, real-time metacognitive regulation during social interactions, and ecologically valid assessments of everyday decision-making. Constructs such as metacognitive mastery in high-stress contexts and dynamic changes in cognitive confidence are also insufficiently measured within current instruments. These gaps highlight the need for next-generation tools that more comprehensively reflect the complexity of metacognitive functioning.

Ecological Momentary Assessment

Future research should examine the application of ecological momentary assessment (EMA) to monitor real-time variation in metacognitive processes. EMA has the potential to offer more ecologically valid insights into the interplay between metacognitive abilities and daily experiences and symptoms in individuals with schizophrenia.

Conclusions

This systematic review highlights the essential role of metacognition in the understanding, diagnosis, and treatment of schizophrenia and related psychiatric conditions. By critically evaluating a range of self-report measures, the review demonstrates the versatility and reliability of these tools in capturing metacognitive abilities across diverse clinical and cultural settings. Beyond basic psychometric validation, the findings emphasize the practical integration of these measures into clinical practice to improve diagnostic accuracy, monitor symptom changes, and guide personalized interventions. Analysis of 36 studies affirms the importance of self-report assessments in measuring self-reflection, cognitive insight, and social functioning, though further optimization is needed. Notably, there is a need for more longitudinal research to assess the stability and responsiveness of these tools over time, and expanded cross-cultural validation to ensure their broader applicability. The capacity of metacognitive assessments to predict real-world functional outcomes, such as vocational and social success, underscores their potential for informing rehabilitation strategies. The review recommends adopting a more integrative approach, combining self-report with behavioral and neuropsychological measures for a comprehensive assessment. Overall, these findings guide future research and clinical practice, advocating for continued innovation in metacognitive assessment and intervention to improve patient outcomes.